Enamel Mineral Content Changes After Bleaching With High and Low Hydrogen Peroxide Concentrations: Colorimetric Spectrophotometry and Total Reflection X-ray Fluorescence Analyses

An In Vitro Study on the Effects of Hydrogen Peroxide-Based Bleaching Agents on Enamel: Field Emission Scanning Electron Microscopy (FESEM) With Energy Dispersive Spectroscopy (EDS) Evaluation

Aim and objective The aim of the present in vitro study is to evaluate the morphological and elemental alterations in enamel following bleaching with hydrogen peroxide-based bleaching agents of different concentrations and pH values when exposed to different treatment times. Materials and method Twenty extracted maxillary central incisors were selected for the study. Tooth samples were prepared by sectioning the tooth cervico-incisally into two halves. The teeth were divided into different groups based on the bleaching protocol and bleaching agent applied: Group IA, Group IB, Group IIA, and Group IIB. Group IA received a 35% hydrogen peroxide-based bleaching agent of pH 6 for 10 minutes with light application. Group IB received a 35% hydrogen peroxide-based bleaching agent of pH 6 for 30 minutes with light activation. Group IIA received a 40% hydrogen peroxide-based bleaching agent of pH 8.5 for 10 minutes with chemical activation. Group IIB received a 40% hydrogen peroxide-based bleaching agent of pH 8.5 for 30 minutes with chemical activation. The morphology of the enamel before and after the application of the bleaching agent was evaluated using field emission scanning electron microscopy. The elemental analysis of enamel between the control and test samples was done with the help of energy dispersive spectroscopy. Results Paired t-test was used to analyze the data obtained from the study. The test samples showed erosive alterations in enamel surface morphology and also a decrease in the concentration of minerals when compared to the corresponding control groups. Conclusions The present study evidences the erosive potential of hydrogen peroxide-based bleaching agents. It can be concluded that bleaching agents containing high concentrations of hydrogen peroxide with acidic pH can cause mineral loss and surface erosion of enamel which is extremely detrimental to the tooth integrity.

Enzymatically Driven Mineralization of a Calcium-Polyphosphate Bleaching Gel

To examined alkaline phosphatase enzyme (ALP) activity and the effects of incorporating it in the thickener solution of a hydrogen-peroxide-based bleaching gel containing calcium-polyphosphate (CaPP) on the orthophosphate (PO43-) levels, bleaching effectiveness, and enamel microhardness. ALP activity was assessed at different pH levels and H2O2 concentrations, and in H2O- and Tris-based thickeners. Circular dichroism (CD) was used to examine the ALP secondary structure in water-, Tris-, or H2O2-based mediums. The PO43- levels were evaluated in thickeners with and without ALP. Enamel/dentin specimens were allocated into the following groups: control (without bleaching); commercial (Whiteness-HP-Maxx); Exp-H (H2O-based); CaPP-H; ALP-H (CaPP+ALP); Exp-T (Tris-based); CaPP-T; and ALP-T (CaPP+ALP). Color changes (ΔE/ΔE00) and the bleaching index (ΔWID) were calculated, and surface (SMH) and cross-sectional microhardness (CSMH) were assessed. The two-way ANOVA and Tukey's post-hoc tests were used to compare ALP and PO43- levels; generalized linear models were used to examine: ΔE/ΔE00/SMH/CSMH; and Kruskal-Wallis and Dunn's tests were used for ΔWID (α = 5%). The ALP activity was higher at pH 9, lower in H2O2-based mediums, and similar in both thickeners. The CD-spectra indicated denaturation of the enzyme upon contact with H2O2. The PO43- levels were higher after incorporating ALP, and the ΔE/ΔE00/ΔWID were comparable among bleached groups. SMH was lower after bleaching in Exp-H, while CSMH was highest in ALP-T.

Effect of the Teeth Whitening Procedure on the Mineral Composition of Oral Fluid

The basis of modern tooth whitening systems is the use of a whitening gel, which usually contains hydrogen peroxide or carbamide peroxide. The study included 81 patients aged 22 to 35 years with a tooth color A2 and a darker color on the Vita Classic scale. The purpose of our research was to identify a new approach to whitening teeth to improve safety and gentleness. To perform this, we assessed the effect of the tooth whitening procedure on the mineral composition of the oral fluid. A new approach to the teeth whitening procedure was to use a mouth retractor and a tool for aspirating the whitening gel, which we developed. Before the procedure, a protective film-forming aerosol, which included sodium ascorbate, was applied. After the tooth whitening procedure, the enamel was remineralized with a sealing liquid for 14 days. The concentrations of calcium and phosphorus in the oral fluid were determined using a spectrophotometer with a set of reagents (Human). The results obtained indicate that the new approach to the teeth whitening procedure contributed to less pronounced changes in the concentrations of calcium (+29.07, p < 0.001) and phosphorus (-14%, p < 0.001) in the oral fluid immediately after the procedure and in combination with the standard procedure for teeth whitening; immediately after this procedure, the calcium concentration increased by 74.4% (p < 0.001), and the phosphorus concentration decreased by 23.07% (p < 0.001). The use of remineralizing agents led to a faster recovery of the initial levels of calcium and phosphorus in the oral fluid.

Effectiveness of changing the color of darker teeth is potentiated by association with violet LED light

BACKGROUND

The effectiveness of in-office bleaching protocols performed with violet LED light either combined with a bleaching agent containing 37% carbamide peroxide, or not, was determined by comparing teeth with different degrees of darkening.

METHODOLOGY

Eighty bovine incisors were separated into groups of "light" teeth (luminosity greater than or equal to B3) and "dark" teeth (less than or equal to A3.5) to receive the protocols: HP - 35% hydrogen peroxide (Whiteness HP), CP - 37% carbamide peroxide (Whiteness SuperEndo), LED - violet LED light (Bright Max Whitening), CPLED - CP associated with the LED. For color analysis the CIEL*a*b* e WID, ΔEab, ΔE00 e ΔWID parameters were used. Data were analyzed using Mann-Whitney, Kruskal-Wallis, Dunn, Friedman or Nemenyi tests (α = 5%).

RESULTS

HP and CP resulted in similar color change values (ΔEab, ΔE00 e ΔWID) for light and dark teeth (p > 0.05). Dark teeth showed better bleaching effectiveness (ΔEab, ΔE00 e ΔWID) than light teeth when CPLED was used (p < 0.05). LED showed color change that were below the limits of acceptability and perceptibility for ΔWID.

CONCLUSION

light teeth are effectively bleached with the use of HP or CP, whereas dark teeth respond better to treatment with the CPLED protocol. Violet LED used alone did not show a satisfactory result.

Influence of violet LED and fluoride-containing carbamide peroxide bleaching gels on early-stage eroded/abraded teeth

PURPOSE

This study evaluated enamel with early-stage erosion/abrasion following bleaching with 20% and 45% carbamide peroxide (CP) gels containing fluoride (F) and irradiated with violet LED (LED).

METHODS

Enamel blocks were immersed in 1% citric acid (5 min) and artificial saliva (120 min) three times to produce early-stage enamel erosion. Simulated toothbrushing was performed only after the first saliva immersion, to provoke enamel abrasion. The erosive/abraded enamel samples were submitted to (n=10): LED/CP20, CP20, LED/CP20_F, CP20_F, LED/CP45, CP45, LED/CP45_F, CP45_F, LED, and control (without treatment). The pH of the gels was assessed, and color (ΔE₀₀) and whiteness index (ΔWI_D) changes were calculated after cycling (T₁), and 7 days from bleaching (T₂). Enamel surface roughness average (Ra) and Knoop microhardness (kg/mm², %SHR) were evaluated at baseline (T₀) at T₁ and T_2. Scanning electron microscopy evaluated the enamel surface morphology at T₂.

RESULTS

The gels' pH was neutral and CP20 and CP45 exhibited no differences in ΔE₀₀ and ΔWI_D (p>0.05) but LED increased these parameters for CP20_F and CP45. Erosion/abrasion significantly decreased mean kg/mm², and the LED group was the only one not increasing microhardness after bleaching (p>0.05). None of the groups fully recovered the initial microhardness. All groups exhibited %SHR similar to the control (p>0.05) and the increase in Ra was detected only after erosion/abrasion. CP20_F groups exhibited a more preserved enamel morphology.

CONCLUSION

Light irradiation combined with low-concentrated CP gel promoted a bleaching effect comparable to the high-concentrated CP. The bleaching protocols did not adversely impact the surface of early-stage eroded/abraded enamel.

Calcium-Polyphosphate Submicroparticles (CaPP) Improvement Effect of the Experimental Bleaching Gels' Chemical and Cellular-Viability Properties

The aim of this research was to develop and characterize the chemical and cellular-viability properties of an experimental high-concentration bleaching gel (35 wt%-H2O2) containing calcium-polyphosphate particles (CaPP) at two concentrations (0.5 wt% and 1.5 wt%). The CaPP submicroparticles were synthesized by coprecipitation, keeping a Ca:P ratio of 2:1. The CaPP morphology, size, and chemical and crystal profiles were characterized through scanning and transmission electron microscopy, energy-dispersive X-ray analysis, and X-ray diffraction, respectively. The assessed bleaching gels were experimental (without CaPP); 0.5% CaPP; 1.5% CaPP; and commercial. The gels’ pH values and H2O2 concentrations (iodometric titration) were determined. The odontoblast-like cell viability after a gel’s exposure was assessed by the MTT assay. The pH and H2O2 concentration were compared through a repeated-measures analysis of variance (ANOVA) and a Tukey’s test and the cell viability through a one-way ANOVA and a Tukey’s test using a GraphPad Prism (α < 0.05). The CaPP particles were spherical (with Ca and P, 135.7 ± 80.95 nm size) and amorphous. The H2O2 concentration decreased in all groups after mixing (p < 0.001). The 0.5% CaPP resulted in more-stable pH levels and higher viability levels than the experimental one (p < 0.05). The successful incorporation of CaPP had a positive impact on the bleaching gel’s chemical and cellular-viability properties when compared to the experimental gel without these particles.

Novel Experimental In-Office Bleaching Gels Containing Co-Doped Titanium Dioxide Nanoparticles

The present study reports on the development and testing of novel bleaching agents containing co-doped metaloxide nanoparticles (NP; 0%, 5%, 10% v/w) and hydrogen peroxide (HP, 0%, 6%, 15%, and 35%). Bovine blocks (n = 200, A = 36 mm2) were obtained and randomly distributed into experimental groups (n = 10/group). NPs were incorporated into gels before bleaching (3 sessions, 7 days apart, 30 min/session, irradiated with violet light-LT). Color changes (ΔE00, ΔWID), mineral content (CO32−, PO43−), and topography were assessed (spectrophotometer, ATR-FTIR, and AFM) before and after bleaching procedures (14 days). Metabolic status and three-dimensional components of non-disrupted Streptococcus mutans biofilms were investigated using a multimode reader and confocal microscopy. The results indicate that ΔE00 and ΔWID significantly increased with NPs’ concentrations and LT. The enamel’s mineral ratio was adversely impacted by HP, but alterations were less pronounced when using NP-containing gels. The enamel’s topography was not damaged by the bleaching protocols tested. The bioluminescence results show that bleaching protocols do not render latent antibacterial properties to enamel, and the confocal microscopy results demonstrate that the 3-dimensional distribution of the components was affected by the protocols. The proposed nanotechnology improved the bleaching efficacy of experimental materials independent of hydrogen peroxide or irradiation and did not adversely impact the enamel’s surface properties or its chemical content.

The influence of the renewal or the single application of the peroxide gel on the efficacy and tooth sensitivity outcomes of in-office bleaching-A systematic review and meta-analysis

OBJECTIVE

To answer the question: "Does the peroxide gel application regimen (single application vs. renewal) influence the efficacy and the tooth sensitivity outcomes of in-office tooth bleaching?"

METHODS

The search was done in Pubmed, Cochrane, LILACS, Scopus, Web of Science, and EMBASE in February 2021 (updated in July 2021). Randomized clinical trials (RCT) comparing the single application vs. the renewal protocols of HP were included. The meta-analyses were performed for the objective (ΔE_ab ), subjective (ΔSGU) color changes, and absolute risk of tooth sensitivity (TS). Heterogeneity was evaluated using Q test (I² ). Cochrane Collaboration tool assessed the risk of bias (RoB). The GRADE evaluated the certainty of evidence.

RESULTS

Five RCT studies remained. Two studies showed high RoB, and three presented some concerns. No significant differences were observed between the protocols in terms of the ΔE_ab , ΔSGU, and TS. ΔE_ab exhibited substantial heterogeneity (I²  = 87%), while ΔSGU (I²  = 60%) and the TS (I²  = 62%) presented a moderate one. The certainty of evidence was considered low or very low, depending on the variable response and the evaluation time.

CONCLUSION

The application regimen (single vs. renewal of HP) did not impact color change or the absolute risk of TS.

CLINICAL SIGNIFICANCE

The renewal of bleaching gel during the in-office appointment may not be necessary. However, there is at least a low certainty of evidence. Because of this, further randomized clinical trials with appropriate methodology on this topic are encouraged.

Effects of dental bleaching protocols with violet radiation on the color and chemical composition of stained bovine enamel

OBJECTIVES

To evaluate the bleaching efficacy of a violet radiation (VR) combined or not with bleaching gels on the color and mineral content of stained teeth.

MATERIAL AND METHODS

Enamel/dentin blocks were obtained and stained (n = 50) with coffee, red wine, tobacco smoke, or were left non-stained. The stained or not-stained blocks (n = 10) were distributed into five bleaching groups (n = 10): VR, CP (37 % carbamide peroxide), VR/CP, HP (35 % hydrogen peroxide), and VR/HP. Color (ΔE_00, ΔL, Δa, and Δb) and whiteness index (ΔWI_D) changes were evaluated after staining and after bleaching using a spectrophotometer. Calcium (Ca), phosphorous (P), and Ca/P contents (in wt%) were measured after bleaching using energy-dispersive X-ray spectroscopy (EDS). Data was statistically analyzed (α = 0.05) using two-way ANOVA and Tukey tests (ΔE_00, ΔWI_D, ΔL, Δb, wt%) or Kruskal-Wallis and Dunn tests (Δa).

RESULTS

VR alone caused higher colorimetric changes on coffee, tobacco and red wine-stained groups compared to non-stained enamel (p < 0.05). VR/CP exhibited higher colorimetric changes compared to CP in coffee and non-stained groups. The VR/CP, HP and VR/HP groups exhibited no change differences (p > 0.05). No differences were observed for the wt% of Ca, P and Ca/P between the groups.

CONCLUSIONS

The violet radiation was more effective in bleaching stained rather than non-stained teeth. VR combined with 37 % carbamide peroxide was as effective as the HP agent. Besides, no adverse effects could be observed in the enamel mineral content, regardless of the bleaching protocol tested, according to the EDS semi-quantitative analysis.

Effectiveness and SEM-EDX analysis following bleaching with an experimental bleaching gel containing titanium dioxide and/or chitosan

The aim of this study was to evaluate the bleaching effectiveness and mineral alterations following the use of experimental bleaching gels that included 6% hydrogen peroxide (HP), titanium dioxide (TiO₂) and/or chitosan in comparison with the routinely used 35% HP bleaching gel. Thirty-six maxillary anterior teeth were divided into three groups according to bleaching agent as follows: Group 1: 6% HP + TiO₂, Group 2: 6% HP + TiO₂ + chitosan, Group 3: 35% HP. Tooth colour was measured with a spectrophotometer before bleaching and after sessions one and two on days 14 and 30, respectively. Colour changes were assessed with the CIEDE2000 and CIELab formulas. Mineral analysis was performed with a scanning electron microscopy-energy dispersive X-ray (SEM-EDX) device before and 14 days after application. The enamel surfaces of randomly selected samples from each group were analysed by SEM. Two-way ANOVA was used to compare differences between groups. All tested materials resulted in significantly increased bleaching compared to the initial colour values (p < 0.05). Group 3 showed significantly more whitening compared to the other groups after the first and second sessions (p < 0.05). However, Group 2 presented prolonged whitening efficiency and reached a bleaching level similar to the 35% HP treatment after 14 and 30 days. The results of the CIEDE2000 and CIELab formulas were found to be correlated (r > 0.6). The increases in Ca were similar in Groups 2 and 3 (p > 0.05) and were significantly higher than that in Group 1 (p < 0.05). p was similarly decreased among all groups (p > 0.05). The combination of 6% HP, chitosan and TiO₂ appears to constitute a promising material for tooth whitening, showing good bleaching efficiency and acceptable mineral alterations.

Effect of violet LED light on in-office bleaching protocols: a randomized controlled clinical trial

Objective

This study evaluated the clinical effect of violet LED light on in-office bleaching used alone or combined with 37% carbamide peroxide (CP) or 35% hydrogen peroxide (HP).

Methodology

A total of 100 patients were divided into five groups (n=20): LED, LED/CP, CP, LED/HP and HP. Colorimetric evaluation was performed using a spectrophotometer (ΔE, ΔL, Δa, Δb) and a visual shade guide (ΔSGU). Calcium (Ca)/phosphorous (P) ratio was quantified in the enamel microbiopsies. Measurements were performed at baseline (T ₀ ), after bleaching (T _B ) and in the 14-day follow-up (T ₁₄ ). At each bleaching session, a visual scale determined the absolute risk (AR) and intensity of tooth sensitivity (TS). Data were evaluated by one-way (ΔE, Δa, ΔL, Δb), two-way repeated measures ANOVA (Ca/P ratio), and Tukey post-hoc tests. ΔSGU and TS were evaluated by Kruskal-Wallis and Mann-Whitney, and AR by Chi-Squared tests (a=5%).

Results

LED produced the lowest ΔE (p<0.05), but LED/HP promoted greater ΔE, ΔSGU and Δb (T ₁₄ ) than HP (p<0.05). No differences were observed in ΔE and ΔSGU for LED/CP and HP groups (p>0.05). ΔL and Δa were not influenced by LED activation. After bleaching, LED/CP exhibited greater Δb than CP (p>0.05), but no differences were found between these groups at T ₁₄ (p>0.05). LED treatment promoted the lowest risk of TS (16%), while HP promoted the highest (94.4%) (p<0.05). No statistical differences of risk of TS were found for CP (44%), LED/CP (61%) and LED/HP (88%) groups (p>0.05). No differences were found in enamel Ca/P ratio among treatments, regardless of evaluation times.

Conclusions

Violet LED alone produced the lowest bleaching effect, but enhanced HP bleaching results. Patients treated with LED/CP reached the same efficacy of HP, with reduced risk and intensity of tooth sensitivity and none of the bleaching protocols adversely affected enamel mineral content.

Effect of in-office bleaching gels with calcium or fluoride on color, roughness, and enamel microhardness

Background

Commercial bleaching gels with remineralizing agents were developed to reduce the adverse effects of dental bleaching. The present study evaluated the effects on teeth of in-office bleaching gels containing 35-40% hydrogen peroxide (HP) with Calcium (Ca) or Fluoride (F).

Material and Methods

Bovine enamel/dentin blocks (4x4x2.5 mm) were randomly divided into the following groups (n=12): no treatment (control); 35% HP (Whiteness HP, FGM); 35% HP with Ca (Whiteness HP Blue, FGM); 40% HP with F (Opalescence Boost, Ultradent). The specimens were analyzed for color (ΔL*, Δa*, Δb*, and ΔE), roughness (Ra), and Knoop microhardness (KHN). The color and KHN data were submitted to ANOVA and Tukey’s test, while Ra values were analyzed using mixed models for repeated measures and Tukey-Kramer’s test (α=0.05).

Results

The bleached groups did not exhibit statistical differences among them for color. For roughness, 35% HP provided a slight increase of Ra, which was statistically different from the control. For microhardness, 35% HP and 40% HP with F presented KHN values that were statistically lower from the control, while the 35% HP with Ca did not statistically differ from the control.

Conclusions

The presence of Ca or F in bleaching gels did not interfere with bleaching efficacy. However, only the enamel exposed to the bleaching gel containing Ca obtained microhardness values similar to unbleached enamel.

Key words:Hydrogen peroxide, tooth bleaching, tooth bleaching agents, laboratory research.

Chemical composition and roughness of enamel and composite after bleaching, acidic beverages and toothbrushing

Background

In this study was assessed the surface roughness and chemical composition of tooth enamel and composite resin after bleaching treatment, immersion in acidic beverages, and simulated toothbrushing.

Material and Methods

One hundred and twenty dental blocks (10 x 10 x 3 mm) were randomly assigned (n = 10) according to surface treatment [none (N), bleaching (B), toothbrushing (T), and B+T] and storage medium [saliva (S), whiskey (W), and orange juice (O)]: experimental groups - N+S, N+W, N+O, B+S, B+W, B+O, S+T, W+T, O+T, B+S+T, B+W+T, and B+O+T. Two bleaching sessions were conducted using 38% hydrogen peroxide (3 applications). Surface roughness was measured using a roughness tester and composition was determined by micro energy-dispersive X-ray fluorescence spectrometry (µ-EDXRF) before and after treatments. Calcium/phosphorus (Ca/P) ratio in enamel and silica (Si) content in composite were evaluated. Data were statistically analyzed by ANOVA and Tukey’s test (α = 0.05).

Results

Overall, increased values of surface roughness for enamel and composite were observed mainly after immersion in orange juice and bleaching/toothbrushing association. Moreover, this association and immersion in whiskey resulted in lower Ca/P ratio and after aging methods, bleached and bleached/toothbrushed groups showed decreased in Ca/P ratio compared to initial values. All groups showed Si content decrease at the end, except the group without surface treatment and immersed in saliva, and bleaching followed by immersion in orange juice and toothbrushing caused the highest Si reduction.

Conclusions

Bleaching and toothbrushing combination strengthened the effects caused by acidic drinks on roughness and chemical composition of enamel and composite.

Key words:Tooth bleaching, toothbrushing, physical properties, chemical properties.

Physicochemical changes in enamel submitted to pH cycling and bleaching treatment

Objective

The purpose of this study was to assess the hardness, mineral content, surface roughness, and micromorphology of sound and slightly demineralized enamels, before and after bleaching procedure using 10% carbamide peroxide.

Methods

Sixty bovine dental blocks were randomly divided into the following two groups: 30 slabs were submitted to three cycles of pH and 30 slabs were noncycled. Hardness (n=10) was measured using the microhardness tester with Knoop indenter under a 50 g load for 5 seconds. The calcium/phosphate (Ca/P) ratio (n=10) was obtained using a micro-energy-dispersive X-ray fluorescence (μ-EDXRF) spectrometer. The measurement of roughness average (n=10) was performed using a surface roughness tester. Specimens were bleached 6 hours/day during 21 days, and then, physicochemical properties were re-evaluated. Two additional specimens were carried out to evaluate surface micromorphology using the scanning electron microscopy. Data were statistically analyzed by ANOVA and Tukey's test (α=0.05).

Results

Sound and slightly demineralized enamels showed no difference in Ca/P ratio after dental bleaching according to the μ-EDXRF analysis, but the Ca/P ratio decreased after bleaching for slightly demineralized enamel. Bleaching treatment decreased the hardness and increased the surface roughness, causing micromorphology alterations.

Conclusion

Therefore, bleaching procedure promoted change in bovine enamel surface and increased the demineralization of slightly demineralized enamel but not affected the mineral content of sound enamel.